• Work with other departments to review questionable claims
• Assessing the quality and credibility of allegations or suspicious situations
• Prioritize cases based on business practices and objectives
• Timely investigation actions
• Relevant claim data gathered , reviewed , and analyzed as evidence
• Written summary of investigated finding with suggested corrective actions , monitoring , and follow-up .
d ) NBI MEDIC Investigation
The Compliance Manager , if necessary , will coordinate or refer to NBI MEDIC the investigation of suspected fraudulent actives of misconduct relating to Part D or MA that could include :
• Suspected , detected or reported criminal , civil and / or administration violations ;
• Allegations extend beyond Part C and / or Part D programs that involve multiple health plans , multiple states and / or widespread schemes
• Allegations involving know patters of fraud
• Scheme with large financial risk to the Medical Program and / or beneficiaries
The Compliance Manager will initiate an investigation of suspected fraudulent actives or misconduct within two ( 2 ) weeks from detection or will refer the matter to NBI MEDIC . The Compliance Manager will retain the NBI MEDIC acknowledgment letter and resolution letter .
II .
Recovery of Duplicate or Erroneous Payments
Hometown Health contracts with numerous commercial client groups and Medicare . Hometown Health ’ s acknowledges its responsibility to be a proper steward and ensure that only eligible employees or beneficiaries are afforded coverage , only medically necessary and medically appropriate services are covered , and that FWA Programs is in place . Additionally , Hometown Health acknowledges its responsibility to recoup overpayments made to providers , vendors , or others as a means of reducing unnecessary medical claims costs . To this end , Hometown Health will remedy and recoup overpayments , erroneous payment , duplicate payments or other payments of an amount in excess of which the provider or vendor is entitled . These recovery efforts are integral to the anti-
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